
<div class="row">
<div class="large-12 columns content-views">
<? echo $system_message;?>
<div class="alert-box">REGISTRATION FORM Part 3: Health History of Child And Discipline</div>
<?$this->load->view('enrollment/notice')?>
<?echo form_open('health','class="custom" data-abide  autocomplete="off"');?>
	<div class="alert-box secondary">HEALTH HISTORY OF CHILD</div>
	<div class="row">
		<div class="large-12 columns">
			<label>What PAST ILLNESSES has the child had? (Please enumerate and specify age it occured)</label>
			<?=form_error('past_illness');?>
			<textarea  name="past_illness" required><?=set_value('past_illness');?></textarea>
			<small class="error">This Field is required.</small>
		</div>
	</div>
	<div class="alert-box secondary">Please Check the Box that corresponds to your medical records.</div>
		<table class="table">
			<tr>
				<td>
					<input type="checkbox" value="1" name="medrec[med_asthma]">
					<label style="display:inline-block;">Asthma</label>
				</td>
				<td>
					<input type="checkbox" value="1" name="medrec[med_heart]">
					<label  style="display:inline-block;">Heart Trouble</label>
				</td>
				<td>
					<input type="checkbox" value="1" name="medrec[med_ulcer]">
					<label  style="display:inline-block;">Stomach Pain/Ulcer</label>
				</td>
			</tr>
			<tr>
				<td>
					<input type="checkbox" value="1" name="medrec[med_cough]">
					<label  style="display:inline-block;">Chronic Cough</label>
				</td>
				<td>
					<input type="checkbox" value="1" name="medrec[med_hb]">
					<label  style="display:inline-block;">High Blood Pressure</label>
				</td>
				<td>
					<input type="checkbox" value="1" name="medrec[med_et]">
					<label  style="display:inline-block;">Eye Trouble</label>
				</td>
			</tr>
			<tr>
				<td>
					<input type="checkbox" value="1" name="medrec[med_d]">
					<label  style="display:inline-block;">Dizziness</label>
				</td>
				<td>
					<input type="checkbox" value="1" name="medrec[med_k]">
					<label  style="display:inline-block;">Kidney Or Bladder Trouble</label>
				</td>
				<td>
					<input type="checkbox" value="1" name="medrec[med_tb]">
					<label  style="display:inline-block;">Tuberculosis</label>
				</td>
			</tr>
			<tr>
				<td>
					<input type="checkbox" value="1" name="medrec[med_ert]">
					<label  style="display:inline-block;">Ear Trouble</label>
				</td>
				<td>
					<input type="checkbox" value="1" name="medrec[med_not]">
					<label  style="display:inline-block;">Nose Or Throat</label>
				</td>
				<td>
					<input type="checkbox" value="1" name="medrec[med_tf]">
					<label  style="display:inline-block;">Typhoid Fever</label>
				</td>
			</tr>
			<tr>
				<td>
					<input type="checkbox" value="1" name="medrec[med_ec]">
					<label  style="display:inline-block;">Epilleptic Case</label>
				</td>
				<td>
					<input type="checkbox" value="1" name="medrec[med_deng]">
					<label style="display:inline-block;">Dengue</label>
				</td>
				<td>
					<input type="checkbox" value="1" name="medrec[med_head]">
					<label  style="display:inline-block;">Frequent Headaches</label>
				</td>
			</tr>
			<tr>
				<td>
					<input type="checkbox" value="1" name="medrec[med_lungs]">
					<label  style="display:inline-block;">Lung Disease</label>
				</td>
				<td>
				</td>
				<td>
				</td>
			</tr>
		</table>
<!-- 	<div class="row">
		<div class="large-6 columns">
			<label>COLDS</label>
			<?=form_error('frequent_colds');?>
			<input type="text" name="frequent_colds" value="<?=set_value('frequent_colds');?>" required>
			<small class="error">This Field is required.</small>
		</div>
		<div class="large-6 columns">
			<label>HEADACHES</label>
			<?=form_error('frequent_headaches');?>
			<input type="text" name="frequent_headaches" value="<?=set_value('frequent_headaches');?>" required>
			<small class="error">This Field is required.</small>
		</div>
	</div>
	<div class="row">
		<div class="large-6 columns">
			<label>STOMACH ACHES</label>
			<?=form_error('frequent_stomachaches');?>
			<input type="text" name="frequent_stomachaches" value="<?=set_value('frequent_stomachaches');?>" required>
			<small class="error">This Field is required.</small>
		</div>
		<div class="large-6 columns">
			<label>DIZZINESS</label>
			<?=form_error('frequent_dizziness');?>
			<input type="text" name="frequent_dizziness" value="<?=set_value('frequent_dizziness');?>" required>
			<small class="error">This Field is required.</small>
		</div>
	</div>
	<div>
		<label>VOMITING</label>
		<?=form_error('frequent_vommiting');?>
		<input type="text" name="frequent_vommiting" value="<?=set_value('frequent_vommiting');?>" required>
		<small class="error">This Field is required.</small>
	</div> -->

	<div>
		<label>Has your child had any major injury in the past? (eg. limbs,joints,head,spine) if yes,specify</label>
		<?=form_error('major_injury');?>
		<textarea name="major_injury"><?=set_value('major_injury');?></textarea>
	</div>
	<div>
		<label>Has your child had any major operations? if yes specify.</label>
		<?=form_error('major_operations');?>
		<textarea name="major_operations"><?=set_value('major_operations');?></textarea>
	</div>
	<div>
		<label>Has your child been diagnosed with any major ailment (eg. heart,epilepsy,asthma) if Yes specify</label>
		<?=form_error('major_ailment');?>
		<textarea name="major_ailment"><?=set_value('major_ailment');?></textarea>
	</div>
	<div>
		<label>What medication/remedy is your child taking?</label>
		<?=form_error('medication_child_taking');?>
		<input type="text" name="medication_child_taking" value="<?=set_value('medication_child_taking');?>" required>
		<small class="error">This Field is required.</small>
	</div>
	<div>
		<label>If your child is suffering from any ailment?, please provide precautionary measures to take.</label>
		<?=form_error('medication_prec');?>
		<input type="text" name="medication_prec" value="<?=set_value('medication_prec');?>" required>
		<small class="error">This Field is required.</small>
	</div>
	<div>
		<label>Is your child allergic to penicillin? aspirin? other medication (specify)?</label>
		<?=form_error('medication_allergy');?>
		<input type="text" name="medication_allergy" value="<?=set_value('medication_allergy');?>" required>
		<small class="error">This Field is required.</small>
	</div>
	<div>
		<label>What is the general eating habit of the child?</label>
		<?=form_error('child_eating_habbit');?>
		<input type="text" name="child_eating_habbit" value="<?=set_value('child_eating_habbit');?>" required>
		<small class="error">This Field is required.</small>
	</div>
	<div>
		<label>Are there any DIETARY RESTRICTIONS or FOOD ALLERGIES? if yes Specify</label>
		<?=form_error('dietary_restrictions');?>
		<input type="text" name="dietary_restrictions" value="<?=set_value('dietary_restrictions');?>" required>
		<small class="error">This Field is required.</small>
	</div>
	<div>
		<label>How do you want the school to help in his/her eating habit?</label>
		<?=form_error('school_help_eating_habbit');?>
		<input type="text" name="school_help_eating_habbit" value="<?=set_value('school_help_eating_habbit');?>" required>
		<small class="error">This Field is required.</small>
	</div>
	
	<hr class="clearfix">
	<div class="alert-box secondary">Discipline</div>
	
	<div>
		<label>Methods of discipline used at home (please be specific)</label>
		<?=form_error('methods_of_discp');?>
		<textarea name="methods_of_discp" required><?=set_value('methods_of_discp');?></textarea>
		<small class="error">This Field is required.</small>
	</div>
	<div>
		<label>Who handles the discipline at home?</label>
		<?=form_error('who_handles_discp_home');?>
		<input type="text" name="who_handles_discp_home" value="<?=set_value('who_handles_discp_home');?>" required>
		<small class="error">This Field is required.</small>
	</div>
	<div>
		<label>How effective is the discipline on your child?</label>
		<?=form_error('how_effective_discp');?>
		<input type="text" name="how_effective_discp" value="<?=set_value('how_effective_discp');?>" required>
		<small class="error">This Field is required.</small>
	</div>
	<div>
		<label>Do you believe in the use of the rod as a form of discipline? Why?</label>
		<?=form_error('rod_discp');?>
		<input type="text" name="rod_discp" value="<?=set_value('rod_discp');?>">
	</div>
	<div>
		<label>Will you allow the TEACHER to use the rod in school ONLY WHEN NECESSARY?</label>
		<?=form_error('allow_teacher_use_rod');?>
		<input type="text" name="allow_teacher_use_rod" value="<?=set_value('allow_teacher_use_rod');?>" required>
		<small class="error">This Field is required.</small>
	</div>
	<div>
		<label>If Not What form of discipline do you suggest we use on your child?</label>
		<?=form_error('what_form_of_discp_use');?>
		<input type="text" name="what_form_of_discp_use" value="<?=set_value('what_form_of_discp_use');?>" required>
		<small class="error">This Field is required.</small>
	</div>
	<div>
		<label>How can the school be of help in supporting your mode if discipline?</label>
		<?=form_error('school_supp_discp');?>
		<input type="text" name="school_supp_discp" value="<?=set_value('school_supp_discp');?>" required>
		<small class="error">This Field is required.</small>
	</div>
	<div>
		<label>What other information can you provide us regarding your child's behavior, personality or development that you believe would aid us in dealing or enhancing his development?</label>
		<?=form_error('other_info_about_child');?>
		<textarea name="other_info_about_child" required><?=set_value('other_info_about_child');?></textarea>
		<small class="error">This Field is required.</small>
	</div>
	<div class="alert-box secondary">IN CASE OF EMERGENCY:</div>
	<div class="row ">
		<div class="large-6 columns">
			<label>Physician</label>
			<input type="text" name="medication_physc_nme" value="<?=set_value('medication_physc_nme');?>" required>
			<?=form_error('medication_physc_nme');?>
			<small class="error">This Field is required.</small>
		</div>
		<div class="large-3 columns">
			<label>Telephone No</label>
			<input type="text" name="medication_physc_con" value="<?=set_value('medication_physc_con');?>" required>
			<?=form_error('medication_physc_con');?>
			<small class="error">This Field is required.</small>
		</div>
		<div class="large-3 columns">
			<label>Blood Type</label>
			<input type="text" name="medication_bt" value="<?=set_value('medication_bt');?>" required>
			<?=form_error('medication_bt');?>
			<small class="error">This Field is required.</small>
		</div>
	</div>
	<div class="row ">
		<div class="large-8 columns">
			<label>Persons authorized to pick up child 	<span class="small-info">Please provide, relationship to the person.</span></label>
			<?=form_error('auth_pickup_bt');?>
			<textarea name="auth_pickup_bt" required><?=set_value('auth_pickup_bt');?></textarea>
			<small class="error">This Field is required.</small>
		</div>
		<div class="large-4 columns">
		</div>
	</div>
	<div class="clearfix"></div>
	<div>
		<input type="hidden" name="sdj_lefg" value="<?=$token;?>">
		<input type="submit" name="fillup_health" value="Finish Enrollment" class="btn btn-primary">
	</div>
<?php echo form_close(); ?>

</div>
</div>